Healthcare Provider Details

I. General information

NPI: 1720128705
Provider Name (Legal Business Name): ALAN JOSEPH HICKEY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

276 CANCO RD
PORTLAND ME
04103-4351
US

IV. Provider business mailing address

276 CANCO RD
PORTLAND ME
04103-4351
US

V. Phone/Fax

Practice location:
  • Phone: 207-773-6177
  • Fax: 207-773-6552
Mailing address:
  • Phone: 207-773-6711
  • Fax: 207-773-6552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number2624
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: